TMR Using a Free Rectus Flap after Transhumeral Amputation.

Targeted muscle reinnervation offers an approach to regain use of the affected extremity through electronic prosthesis while limiting phantom pain and neuroma limb production or pain. In this case report, we present the first reported case of leveraging the rectus flap for targeted muscle reinnervation. The case herein is of a 28-year-old woman who sustained a severe right upper extremity crush injury while being involved in a vehicular roll-over collision requiring right transhumeral amputation. Plastic surgery, orthopedic surgery, and vascular surgery were consulted to manage the right upper extremity injury.

Combined TMR and RPNI in a vasculopathy patient: A case report.

TMR (targeted muscle reinnervation) or RPNI (regenerative peripheral nerve interface) have been the standard after nerve injuries. In this case report, we explain our approach in combining these two techniques (TMRpni) for a patient undergoing left above-the-knee amputation. Using this method, both phantom and nerve pain were reduced in our patient's case. As this technique becomes more well understood and widely adopted, amputee patients may achieve a greater quality of life post operation.

Postsurgical Outcomes with Meshes for Two-stage Prosthetic Breast Reconstruction in 20,817 Patients.

Use of acellular dermal matrices (ADMs) for tissue expander breast reconstruction remains controversial with an uncertain safety and efficacy profile. This study analyzes the rates and factors for reoperation and postoperative infection in patients who underwent tissue expander breast reconstruction with and without ADM. Methods: Patients who underwent breast reconstruction with and without ADM were identified from the National Surgical Quality Improvement Program database utilizing CPT codes. Covariates included patient demographics, preoperative comorbidities, and operative characteristics, while outcomes of interest were postoperative infection and reoperation. Univariate and multivariate analyses were performed to identify predictors of adverse outcomes. Results: There were 8334 patients in the ADM cohort and 12,451 patients who underwent tissue expander breast reconstruction without ADM. There were significantly fewer reoperations in the non-ADM cohort (5.4%) compared to the ADM cohort (7.7%) (P < 0.0001), with infection and hematoma as the most common etiologies in both cohorts. Surgical infections were also more prevalent in the ADM cohort (4.7%) compared with the non-ADM cohort (3.6%) (P < 0.0001). Univariate and multivariate analysis of the tissue expander breast reconstruction cohort revealed race, obesity, hypertension, smoking status, albumin, and operative time as predictive for infection risk, while race, obesity, hypertension, smoking, albumin, operative time, and age were significant for reoperation. Conclusion: Our study of 20,817 patients revealed significantly higher risk of infection and reoperation in patients who underwent breast reconstruction utilizing ADM versus without ADM. Patients considering ADM for breast reconstruction should engage in discussion with their surgeon about complications, aesthetics, and cost.

The Positive Patient Experience: A Comprehensive Analysis of Plastic Surgery Online Reviews.

BACKGROUND: Subjective online physician evaluation is an important component of patient decision-making. Understanding reviews may improve satisfaction and build positive online reputation. OBJECTIVES: The aim of this study was to analyze and compare the top predictive factors driving patient satisfaction across the most popular plastic surgery procedures. METHODS: Online reviews were analyzed from RealSelf, Yelp, and Google for the 5 highest-rated plastic surgeons in 6 US metropolitan areas. Blank, non-English, consultation, duplicate, and unrelated reviews were excluded. Data from free-text reviews included physician rating, patient-reported reasons for rating, procedure, and complications. Univariate analysis was performed to compare predictive factors of online ratings. RESULTS: In total, 11,078 reviews were included. RealSelf had the highest average rating (4.77), and Yelp had the lowest (4.66). Reviews in Miami, Philadelphia, New York City, and Chicago were mostly published on RealSelf, whereas Houston and Los Angeles mostly used Google and Yelp, respectively. Reconstructive procedures were rated significantly higher than cosmetic procedures (P = 0.035). Aesthetic appearance was the strongest predictor of rating across all procedures. Buccal fat removal (98.8%) and abdominoplasty (98.1%) had the highest satisfaction, and Brazilian butt lift had the lowest (88.2%) (P < 0.001). Additional significant contributors included staff interaction, bedside manner, health outcomes, complications, and postoperative care (P < 0.001). CONCLUSIONS: Although aesthetic outcome is an important predictor of satisfaction, other aspects of care, such as bedside manner and staff interaction, provide an important foundation of support. Excellent patient-surgeon communication and postoperative care may mitigate patient dissatisfaction and elicit high-satisfaction online patient reviews.

Labiaplasty: Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: Labiaplasty is an increasingly popular procedure performed for both cosmetic and pathologic etiologies. Questions have been raised regarding the efficacy of the procedure, especially for cosmetic etiologies. OBJECTIVES: The aim of this study was to examine the complication profiles of labiaplasties for both cosmetic and pathologic etiologies. METHODS: The 2005 to 2017 National Surgical Quality Improvement Program database was analyzed for patients who, according to the relevant Current Procedural Terminology code, had undergone labiaplasties. Our cohort was further separated into cosmetic and pathologic groups based on International Classification of Diseases codes. Information was collected on patient demographic characteristics, patient comorbidities, and operative variables. Outcomes of interest included surgical complications and delayed length of stay (DLOS). A univariate analysis and multivariate logistic regression were applied to determine statistically significant predictors of our outcomes of interest for both etiologies. RESULTS: There were 640 patients in the cosmetic cohort and 1919 patients in the pathologic cohort. There were no significant differences in rates of surgical complications between the 2 groups, but there was a statistically significant increase in length of stay for the pathologic group. Univariate analysis revealed operative time and plastic surgeon specialty to be predictive of DLOS in the cosmetic cohort. No covariates were implicated with multivariate analysis for either surgical complications or for DLOS in the cosmetic cohort. CONCLUSIONS: Our findings suggest that cosmetic labiaplasty is a safe and efficacious procedure with low complication rates and no predictors of adverse outcomes.

A Longitudinal, Geographical, and Descriptive Analysis of Political Contributions of Plastic Surgeons.

BACKGROUND: Political contributions from healthcare providers are essential to shaping healthcare policy and allow physicians to expand their influence on a national level. Political Action Committees in particular provide a useful avenue for unifying contributions for the interest of a specific community. This study examined the geographical distribution, temporal pattern, and overall nature of the political contributions made by plastic surgeons. METHODS: The Federal Election Commission was analyzed for political contributions made by plastic surgeons from 2003 to 2021 using the search terms "plastic surgeon," "microsurgeon," and "craniofacial" as well as physician contributions to PlastyPAC. Contributions were categorized based on political parties (Democratic, Republican, and independent parties), and further analyzed based on state distribution and year of contribution. Spatial distribution data were then visualized using heatmaps for each state. RESULTS: The total sum of contributions between 2003 and 2021 from plastic surgeons was $5,306,605, with $1,737,178.51 for the Republican party, $962,773.26 for the Democratic party, and $2,604,149.86 for independent parties. Political funding of PlastyPAC consisted of 47.3% of the overall political contributions. There was no significant trend through the years in the overall contribution amount. The states with the most political contributions were California, New York, Florida, and Texas. CONCLUSIONS: The temporal stagnation of total political contributions and decline in recent PlastyPAC funding from plastic surgeons support an increased political awareness for new plastic surgeons. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of Chronic Wounds Secondary to Injectable Drug Use with a Biodegradable Temporizing Matrix.

Injectable drug use in the upper extremity often leads to chronic wounds complicated by osteomyelitis. Conventional reconstructive options are often not feasible and/or are contraindicated in this patient population. We have started using a synthetic, biodegradable temporizing matrix (BTM) for the treatment of these patients. We hypothesize that BTM is a safe, low-risk, and low-morbidity alternative reconstructive option. We report outcomes after staged debridement and BTM application followed by split-thickness skin grafting for two patients with large, chronic bilateral forearm wounds with concomitant osteomyelitis confirmed by MRI and biopsy. No acute surgical complications were encountered and at a mean follow-up of 13 months, both patients had maintained stable soft-tissue coverage. Reconstruction using BTM is a novel treatment option that can simplify the reconstruction, reduce donor-site morbidity, and optimize success for patients with chronic wounds resulting from injectable drug use. Initial outcomes are promising; however, further comparative studies are needed to better evaluate long-term outcomes of this technique.

The importance of surgical maneuvers during treatment of frontal migraines (site I): A prospective, randomized cohort study evaluating foraminotomy/fasciotomy, myectomy, and arterectomy.

BACKGROUND: The current prospective, blinded, randomized cohort study aims to delineate the relative contribution of different surgical treatments for frontal migraines. METHODS: Patients undergoing migraine surgery in the frontal region (site I) were prospectively enrolled and blindly randomized into one of the following four groups: (1) myectomy alone, (2) myectomy and foraminotomy/fasciotomy, (3) myectomy and arterectomy, and (4) foraminotomy/fasciotomy alone. Pre- and post-surgical migraine headache severity, duration, Migraine Headache Index (MHI) score, and migraine-free days (MFDs) were obtained. RESULTS: Thirteen patients agreed to participate in the study. For all patients, the mean pre- and post-operative MHI scores demonstrated a significant improvement from 52.6 (3.8-85) to 4.7 (0-21.3) (p = 0.0001). Thirty-one percent of patients required a site I revision that included an arterectomy. Patients who had an arterectomy at their initial surgery demonstrated statistically significant improvement in both frequency (12 vs. 6.11; p = 0.02) and MHI scores (51.71 vs. 5.55; p < 0.01). Arterectomy patients also demonstrated a significant improvement in the number of MFDs following surgery, from 18 to 24 MFDs (p = 0.021). Those patients not undergoing arterectomy demonstrated statistically significant improvements in the number of MFDs after their initial surgery (13.25 MFDs, p = 0.01), but the improvement was significantly less when compared to the arterectomy group (13.25 vs. 24 MFDs; p = 0.026). Following revision arterectomy, both groups had statistically equivalent improvement in MFDs (20.75 vs. 24 MFDs; p = 0.178). CONCLUSIONS: These findings suggest that arterectomy is necessary for successful treatment of frontal migraines (site I).

Three-Dimensional Changes in the Midface Following Malar Calcium Hydroxyapatite Injection in a Cadaver Model.

BACKGROUND: Three-dimensional (3D) changes in the midface following malar calcium hydroxyapatite (CaHa) injection have not been systematically analyzed. OBJECTIVES: The authors analyzed 3D volume changes in midface and naso-labial fold (NLF) volume, as well as lateral movement in the NLF/naso-labial crease (NLC) junction following malar injection of CaHa in a cadaver model. METHODS: A single surgeon injected CaHa in the supraperiosteal plane. Sequential images were obtained with the VECTRA 3D system pre- and post-1.5- and 3-cc CaHa injections. All measurements were performed by a single examiner. Injection location was verified anatomically. RESULTS: Injections were performed in 16 fresh cadaver hemi-faces. Maximal increases in projection were centered on the malar injection site, with associated decreases in projection and volume in the infero-medial locations. Relative mean increases in volume of 3.16 cc and 4.94 cc were observed following the 1.5-cc and 3-cc injections, respectively. There was a relative decrease in the volume of the NLF of -0.3 cc and -0.4 cc following the 1.5- and 3-cc injections, respectively. Injection of CaHa was associated with lateral movements of the NLF-NLC junction at the level of the nasal sill, philtral columns, and oral commissure, measuring 2.7, 2.5, and 1.9 mm and 2.8, 2.9, and 2.4 mm following the 1.5- and 3-cc injections, respectively. Anatomical dissection verified the location in the supraperiosteal space and within the middle malar fat pad. CONCLUSIONS: Following malar CaHa injection, 3D photographic analysis showed a measureable lifting effect with recruitment of ptotic tissue and lateral movement of the NLF-NLC junction in a cadaver model.

Hand surgery volume and the US economy: is there a statistical correlation?

BACKGROUND: To the best of our knowledge, there have been no previous studies evaluating the correlation of the US economy and hand surgery volume. Therefore, in light of the current recession, our objective was to study our institution's hand surgery volume over the last 17 years in relation to the nation's economy. METHODS: A retrospective analysis of our institution's hand surgery volume, as represented by our most common procedure (ie, carpal tunnel release), was performed between January 1992 and October 2008. Liposuction and breast augmentation volumes were chosen to serve as cosmetic plastic surgery comparison groups. Pearson correlation statistics were used to estimate the relationship between the surgical volume and the US economy, as represented by the 3 market indices (Dow Jones, NASDAQ, and S&P500). RESULTS: A combined total of 7884 hand surgery carpal tunnel release (open or endoscopic) patients were identified. There were 1927 (24%) and 5957 (76%) patients within the departments of plastic and orthopedic surgery, respectively. In the plastic surgery department, there was a strong negative (ie, inverse relationship) correlation between hand surgery volume and the economy (P < 0.001). In converse, the orthopedic department's hand surgery volume demonstrated a positive (ie, parallel) correlation (P < 0.001). The volumes of liposuction and breast augmentation also showed a positive correlation (P < 0.001). CONCLUSION: To our knowledge, we have demonstrated for the first time an inverse (ie, negative) correlation between hand surgery volumes performed by plastic surgeons in relation to the US economy, as represented by the 3 major market indices. In contrast, orthopedic hand surgery volume and cosmetic surgery show a parallel (ie, positive) correlation. This data suggests that plastic surgeons are increasing their cosmetic surgery-to-reconstructive/hand surgery ratio during strong economic times and vice versa during times of economic slowdown.

P3a from visual stimuli: task difficulty effects.

The P3a event-related brain potential (ERP) was elicited using a visual three-stimulus oddball paradigm (target, standard, distracter) in which participants responded only to the target. Discrimination task difficulty between the target and the standard was manipulated by varying the size of the standard stimulus circle relative to a constant target stimulus circle across three conditions (easy, medium, hard). A large checkerboard pattern was employed for the distracter stimulus across all tasks. Error rate and response time increased with increases in task difficulty, so that the task difficulty manipulation was successful. Distracter P3a amplitude increased and target P3b decreased somewhat with increases in task difficulty. The findings suggest that increased perceptual discrimination difficulty between the target and standard stimuli increases P3a amplitude. Theoretical implications are discussed.